BABCP Response - NICE Consultation January 2022

Expansion Into Long Term Conditions By IAPT Is Quackery

so challenge Clinical Commissioning Groups on the value for money – no better than homeopathy. Studies of CBT  for long term conditions (LTCs) show either no effect, see Serfaty et al study (2019) on cancer

and/or rely on a self report measure of questionable real world significance, see the Everitt et al  (2019) study of irritable bowel syndrome In the Everitt et al (2019) study outcome was assessed primarily by the patient’s completion of a 5 item measure of the severity of IBS (IBS-SSS) rather than a clinician independent of the study asking the IBS-Adequate Relief  question ‘ since… have you had adequate relief of your IBS’. Usually the IBS-AR uses the time frame of the past seven days but in the context of assessing CBT it could be since entering the study for a control group or since cbt for those having cbt.  The correlation between the IBS-AR and IBS-SSS though significant is small see Passos et al (2009)

The authors of the Everitt et al (2019) study appear not to realise  that use of a self-report measure as the primary outcome measure introduces a demand effect for clients undergoing cbt, they don’t want to feel that they have wasted their time. Further the Passos et al (2009) study showed that the IBS-AR is much less subject to fluctuation than the IBS-SSS. Arguably the IBS-AR is of much greater social significance, addressing whether an intervention makes a real world difference. 

It is worrying that Everitt et al (2019) opine:

‘Offering both web-CBT and telephone-CBT in NHS services such as Improving Access to Psychological Therapy could allow many patients to gain substantial benefits with web-CBT with minimal therapist input while allowing a step-up approach to telephone-CBT for those needing additional

IAPT will surely jump on this to justify empire building and likely ignore the caution of Serfaty et al (2019) 

‘our results suggest that resources for a relatively costly therapy such as IAPT-delivered CBT should not be considered as a first-line treatment for depression in advanced cancer. Indeed, these  findings raise important questions about the need to further evaluate the use of IAPT for people with comorbid severe illness’

If as seems likely Clinical Commisioning Groups fund IAPT’s expansion into LTCs they should be asked to justify this expenditure in the abscence of any empirical base.  

Dr Mike Scott

17 replies on “Expansion Into Long Term Conditions By IAPT Is Quackery”

The title may imply that the expansion with regard to long term conditions is a new or recent development. But it was always the intention of IAPT to treat lots of patients with long term conditions and medically unexplained symptoms, this is what IAPT was always about – to save money from the physical healthcare budget – as laid out in Layard and Clark’s book ‘Thrive: The Power of Psychological Therapy’. The economic model is that the physical healthcare savings made by treating these patients with CBT will pay for the service for everyone else who needs it.

So what happens if those savings don’t materialize? It seems to me that they are guarding/have guarded against that to an extent by a) asking applicants for IAPT funding to describe how they envisage reductions to their physical healthcare spending will be made, and b) suggesting that commissioners should consider disinvesting in their physical healthcare services on the basis of merely anticipated savings to their physical healthcare budgets (suggested by preliminary evidence of savings from one particular service/region). Meanwhile the aim is that 2/3rds of new IAPT clients will come from the LTC and MUS groups. So to my mind this has little to do with helping people with mental health difficulties, but has a lot to do with the drive to reduce secondary care, cut hospital and outpatient services and push cheap (or non-existent) care in the community. If I was being generous I’d say that it was about wanting to prove a pie-in-the-sky hypothesis (that links psychotherapy with economics) that these people earnestly believe in, but if it was a beneficent endeavour then wouldn’t they deliver the services anyway, without set target groups, to anyone who wanted them, and view any physical healthcare savings arising as a secondary gain/ a coincidental bonus, rather than wanting spending cut up front? (Instead they appear to have marketed the strategy to government/s as a ‘no-brainer’ – see David Marks’ Editorial ‘IAPT under the microscope’ – and David Clark’s presentation here - )

Some people with ‘medically unexplained symptoms’ are suffering in the most horrendous ways, deprived of any good biomedical help by the NHS (in terms of both treatment and research), with IAPT being the recommended treatment. The MUS strategy in the UK undermines patient safety on a monumental scale, potentially risking the health of millions of people each year. This is a national scandal and yet few people seem to care about it. And now in relation to long term conditions we hear in the news about unacceptable delays in spotting secondary breast cancer- – so why IS this happening? Why don’t GPs believe their female patients when they come to them with their symptoms? What could possibly make them think that their patients’ symptoms don’t require referrals to secondary care, I wonder?

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